Online Live Victim Impact Panel Registration

Live Online Survivor Speakout Victim Impact Panel

Survivor Speakout Online Victim Impact Panel is a 2-hour live presentation, not a recorded class. There is no test. Once the form has been submitted you will be directed to a page to pay your $55.00 fee. It is your responsibility to ensure that your county accepts online victim impact panels. Ask your probation officer.

NOTE: You must have a reliable pad, laptop or computer to attend Survivor Speakout victim impact panel online. Cell phones are not acceptable. If you do not have a laptop or computer, do not register to attend a Survivor Speakout online panel. 

Read the full guidelines to attend ONLINE

You will receive a confirmation email after submitting this form. If you do not receive the confirmation email, check your spam/junk folder.

Once you have completed the victim impact panel your probation officer will be notified.

Complete this form and have a recent head shot image of yourself ready to submit to attend a Survivor Speakout Victim Impact Panel ONLINE USING ZOOM.

Guidelines *

• I have read and understand all of the Survivor Speakout Guidelines to attend ONLINE USING ZOOM

Technology required *

• I understand that I must have a laptop or computer to attend online ONLINE USING ZOOM

No cell phones *

• I understand that I cannot use a cell phone to attend Survivor Speakout ONLINE USING ZOOM and my cell phone must be turned off during the panel

Your Personal Information

Last Name / First Name *

First

Last

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Your age *Choose one15-1819-2526-3031-3536-4041-4546-5051-5556-6061-6566-7071-7576-8081-8586-9091-9596-100

Telephone *

Email *

Request the date you would like to attend Survivor Speakout ONLINE LIVE

Date *Choose a date to attend ONLINEThursday, September 21st - 6pm-8pmWednesday, September 27th - 10am-NoonThursday, October 5th - 6pm-8pmWednesday, October 18th - 6pm-8pmWednesday, November 1st - 6pm-8pmThursday, November 9th - 10am-NoonWednesday, November 14th - 6pm-8pmThursday, December 14th - 10am-NoonWednesday, January 10, 2024 - 6pm-8pmSaturday, January 13, 2024 - 10am-NoonThursday, January 25, 2024 - 6pm-8pmWednesday, February 7, 2024 - 6pm-8pmThursday, February 22, 2024 - 10am-NoonWednesday, February 28, 2024 - 6pm-8pm

On what charges were you arrested?

Charge *Choose oneDWIDUIOWIOUIPIMinor in ConsumptionOpen ContainerIllegal possession of alcoholDrug RelatedOther

If you chose 'Other' above, please tell us what you were charged with

Your probation officer and date your probation ends

Probation officer *Choose oneAbigail O’BrianAlex RedmondAlexandria RedmondAmber HoffertAndrew LillpopAshley StarlingBetsy SchulerBen NeureiterBrian DayBrittany StodghillCaleb LazanoCaleb NanzerCarmen SimsCarol NienaberCaroline CathcartChad BoruffCheryl KochChad KoebckeChad UlmerChantel CloudChristina CandiaCorey WalkerCourtney SacchiniDwight StevensonElizabeth KriegErinn McCluneyFaith EdwardsFaith OliverJesse TuckerJustin CulpKevin McCleeseKristin UshmanLeah BakerMakayla HuseMalachi TaylorMariah MyersMcKinzee TerryMegan CarusoMegan MorgusonMelody SearsPatrick GillianRebecca ShrockReid RoetheRichard PorterRichard MartinezRonda GibsonShelby WiserStephen OwensSteve RobertsSuzan Shrock-GideonThomas PurkhiserTim MillerZach MinardoMy probation officer is not listedI do not know my probation officer's nameI have a plea/diversion agreement

If your probation officer's name is not listed, enter their name here

Date probation ends *

If you are not sure of the exact date, choose the last day of the month your probation ends

Who is the judge presiding over your case?

Judge *Choose oneThe Honorable Rhett StuardThe Honorable Dan ZielinskiThe Honorable Mark SmithThe Honorable Stephanie Lemay-LukenThe Honorable Charles E. HostetterThe Honorable Robert FreeseThe Honorable David ColemanThe Honorable Lindsay R. WalkerThe Honorable James D. SpencerThe Honorable Maureen T. OwenThe Honorable Bruce E. PetitThe Honorable J. Jeffrey EdensThe Honorable Matt HeadleyThe Honorable Tammy SomersThe Honorable Clayton A. GrahamThe Honorable Amy JonesThe Honorable Ryan TanselThe judge presiding over my case is not listedI do not know my judge's name

If you know the name of your judge, but they are not on the list, enter it here

County information

In which county were you arrested, charged or convicted? *Choose oneAdams Allen Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. JosephScott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley I live outside of Indiana

In which county do you live? *Choose oneAdams Allen Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. JosephScott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley

Comments/Questions

To attend online, upload a recent, clear head shot photo of yourself (Only .jpg, jpeg, .png, .gif files that are less than 4MB allowed) *

Click or drag a file to this area to upload.

We must have a recent, clear head shot photo of you to attend ONLINE or you must register to attend IN PERSON.

Submit Registration Request